Step Therapy ProgramEffective: 12/1/2019

Step therapy is a process that requires you to try one drug before your plan will cover another drug. For example, if Drug A and Drug B treat the same medical condition, Health Alliance Medicare may require you to try Drug A fi rst. If Drug A doesn’t work for you, we will then cover Drug B. This requirement encourages you to try safer or typically more effective drugs before we will cover another drug. Here is our current list of drugs on step therapy.

For an exception to the step therapy program or to request a written copy of the coverage criteria, please contact Health Alliance Medicare Services at 1-800-965-4022 for Illinois and Western Indiana members, 1-877-917-8550 for Iowa members, 1-877-749-3253 for Ohio and Eastern Indiana members and 1-877-750-3350 for Washington members. TTY users, please call 711. Representatives are available 8 a.m. to 8 p.m., Monday through Friday.

This list is subject to change.

Health Alliance Medicare is a Medicare Advantage Organization with a Medicare contract. Enrollment in Health Alliance Medicare depends on contract renewal.

This information is not a complete description of benefi ts. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefi ts and copayments/co-insurance may change on January 1 of each year.

This information is available for free in other languages. Please call our customer service number at 1-877-933-2564 (TTY: 711), 8 a.m. to 8 p.m. daily from October 1 to February 14 and weekdays the rest of the year.

Esta información está disponible sin cargo en otros idiomas. Para obtener información adicional, llamar a nuestro número de servicio al cliente al 1-877-933-2564 (TTY: 711). Nuestro horario es de 8 a.m. a 8 p.m., los 7 días de la semana, 1 de octubre a 14 de febrero, y lunes a viernes el resto del año.

iph-STlist19-1219Y0034_16_42312

Step Therapy Criteria HAMP 2019 Effective: December 1, 2019

Formulary ID 19340, Version 20 1

ANTIDEPRESSANTS - HAMP Products Affected • Brintellix • Fetzima • Fetzima Titration Pack • Fluvoxamine Maleate Er

• Pexeva • Trintellix • Viibryd • Viibryd Starter Pack

Details

Criteria PRIOR PAID CLAIM OF GENERIC ANTIDEPRESSANT

Formulary ID 19340, Version 20 2

ANTIFUNGAL TOPICAL-HAMP Products Affected • Mentax • Naftifine Hcl

• Naftifine Hydrochloride • Naftin GEL

Details

Criteria PRIOR PAID CLAIM OF GENERIC TOPICAL ANTIFUNGAL

Formulary ID 19340, Version 20 3

APTIOM-HAMP Products Affected • Aptiom

Details

Criteria PRIOR PAID CLAIM FOR OXCARBAZEPINE

Formulary ID 19340, Version 20 4

ATYPICAL ANTIPSYCHOTICS-HAMP Products Affected • Abilify Maintena • Aristada • Aristada Initio • Fanapt • Fanapt Titration Pack • Invega Sustenna • Invega Trinza • Latuda

• Olanzapine INJ • Paliperidone Er • Rexulti • Risperdal Consta • Saphris • Vraylar • Ziprasidone Hcl • Zyprexa Relprevv

Details

Criteria PRIOR PAID CLAIM OF GENERIC ATYPICAL ANTIPSYCHOTIC

Formulary ID 19340, Version 20 5

BRIVIACT-HAMP Products Affected • Briviact

Details

Criteria PRIOR PAID CLAIM WITH A GENERIC ANTI-SEIZURE MEDICATION

Formulary ID 19340, Version 20 6

DALIRESP-HAMP Products Affected • Daliresp

Details

Criteria PRIOR USE OF INHALED CORTICOSTEROID OR ICS COMBO AGENT

Formulary ID 19340, Version 20 7

DIFICID-HAMP Products Affected • Dificid

Details

Criteria PRIOR PAID CLAIM OF METRONIDAZOLE OR VANCOMYCIN

Formulary ID 19340, Version 20 8

DIPEPTIDYL PEPTIDASE-4 (DPP4) ENZYME INHIBITORS-HAMP Products Affected • Janumet • Janumet Xr • Januvia • Jentadueto • Jentadueto Xr

• Kazano • Nesina • Oseni • Tradjenta

Details

Criteria PRIOR PAID CLAIM FOR METFORMIN (GENERIC GLUCOPHAGE), METFORMIN ER OR GLIPIZIDE/METFORMIN (GENERIC METAGLIP), GLIPIZIDE, GLIPIZIDE ER/XL, GLIMEPIRIDE, PIOGLITAZONE/METFORMIN (GENERIC ACTOPLUS MET), PIOGLITAZONE/GLIMEPIRIDE (GENERIC DUETACT) OR RIOMET WITHIN THE PAST 120 DAYS

Formulary ID 19340, Version 20 9

GLP1 AGONIST-HAMP Products Affected • Bydureon • Bydureon Bcise • Bydureon Pen

• Byetta • Trulicity • Victoza

Details

Criteria PRIOR PAID CLAIM FOR METFORMIN (GENERIC GLUCOPHAGE), METFORMIN ER OR GLIPIZIDE/METFORMIN (GENERIC METAGLIP), GLIPIZIDE, GLIPIZIDE ER/XL, GLIMEPIRIDE, PIOGLITAZONE/METFORMIN (GENERIC ACTOPLUS MET), PIOGLITAZONE/GLIMEPIRIDE (GENERIC DUETACT) OR RIOMET WITHIN THE PAST 120 DAYS

Formulary ID 19340, Version 20 10

GRALISE-HAMP Products Affected • Gralise • Gralise Starter

Details

Criteria PRIOR USE OF GENERIC GABAPENTIN

Formulary ID 19340, Version 20 11

SODIUM GLUCOSE CO-TRANSPORTER 2 INHIBITOR-HAMP Products Affected • Invokamet • Invokamet Xr

• Invokana • Jardiance

Details

Criteria PRIOR PAID CLAIM FOR METFORMIN (GENERIC GLUCOPHAGE), METFORMIN ER OR GLIPIZIDE/METFORMIN (GENERIC METAGLIP), GLIPIZIDE, GLIPIZIDE ER/XL, GLIMEPIRIDE, PIOGLITAZONE/METFORMIN (GENERIC ACTOPLUS MET), PIOGLITAZONE/GLIMEPIRIDE (GENERIC DUETACT) OR RIOMET WITHIN THE PAST 120 DAYS

Formulary ID 19340, Version 20 12

SPRITAM-HAMP Products Affected • Spritam

Details

Criteria PRIOR PAID CLAIM FOR LEVETIRACETAM

Formulary ID 19340, Version 20 13

TRAMADOL-HAMP Products Affected • Tramadol Hcl Er

Details

Criteria PRIOR PAID CLAIM OF TRAMADOL IMMEDIATE RELEASE

Formulary ID 19340, Version 20 14

ULORIC-HAMP Products Affected • Uloric

Details

Criteria PRIOR PAID CLAIM OF ALLOPURINOL

Formulary ID 19340, Version 20 15

XULTOPHY-HAMP Products Affected • Xultophy 100/3.6

Details

Criteria PRIOR PAID CLAIM FOR GLUCAGON-LIKE PEPTIDE-1 (GLP-1) OR BASAL INSULIN

Formulary ID 19340, Version 20 16

INDEX

A

Abilify Maintena ................................................... 4 Antidepressants - Hamp ........................................ 1 Antifungal Topical-hamp ...................................... 2 Aptiom ................................................................... 3 Aptiom-hamp ........................................................ 3 Aristada ................................................................. 4 Aristada Initio ........................................................ 4 Atypical Antipsychotics-hamp .............................. 4

B

Brintellix................................................................ 1 Briviact .................................................................. 5 Briviact-hamp ........................................................ 5 Bydureon ............................................................... 9 Bydureon Bcise ..................................................... 9 Bydureon Pen ........................................................ 9 Byetta .................................................................... 9

D

Daliresp ................................................................. 6 Daliresp-hamp ....................................................... 6 Dificid.................................................................... 7 Dificid-hamp ......................................................... 7 Dipeptidyl Peptidase-4 (dpp4) Enzyme Inhibitors-

hamp .................................................................. 8

F

Fanapt .................................................................... 4 Fanapt Titration Pack ............................................ 4 Fetzima .................................................................. 1 Fetzima Titration Pack .......................................... 1 Fluvoxamine Maleate Er ....................................... 1

G

Glp1 Agonist-hamp ................................................ 9 Gralise .................................................................. 10 Gralise Starter ...................................................... 10 Gralise-hamp ........................................................ 10

I

Invega Sustenna ..................................................... 4 Invega Trinza ......................................................... 4 Invokamet ............................................................ 11 Invokamet Xr ....................................................... 11 Invokana ............................................................... 11

J

Janumet .................................................................. 8 Janumet Xr ............................................................. 8 Januvia ................................................................... 8 Jardiance .............................................................. 11 Jentadueto .............................................................. 8 Jentadueto Xr ......................................................... 8

K

Kazano ................................................................... 8

L

Latuda .................................................................... 4

M

Mentax ................................................................... 2

N

Naftifine Hcl .......................................................... 2 Naftifine Hydrochloride ......................................... 2 Naftin ..................................................................... 2 Nesina .................................................................... 8

Formulary ID 19340, Version 20 17

O

Olanzapine ............................................................. 4 Oseni...................................................................... 8

P

Paliperidone Er ...................................................... 4 Pexeva ................................................................... 1

R

Rexulti ................................................................... 4 Risperdal Consta ................................................... 4

S

Saphris ................................................................... 4 Sodium Glucose Co-transporter 2 Inhibitor-hamp

......................................................................... 11 Spritam ................................................................ 12 Spritam-hamp ...................................................... 12

T

Tradjenta................................................................ 8

Tramadol Hcl Er .................................................. 13 Tramadol-hamp .................................................... 13 Trintellix ................................................................ 1 Trulicity.................................................................. 9

U

Uloric ................................................................... 14 Uloric-hamp ......................................................... 14

V

Victoza ................................................................... 9 Viibryd ................................................................... 1 Viibryd Starter Pack ............................................... 1 Vraylar ................................................................... 4

X

Xultophy 100/3.6 ................................................. 15 Xultophy-hamp .................................................... 15

Z

Ziprasidone Hcl ...................................................... 4 Zyprexa Relprevv................................................... 4

cmp-nondiscrim15MED-0719

DISCRIMINATION IS AGAINST THE LAW Health Alliance complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Health Alliance does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Health Alliance: • Provides free aids and services to people with disabilities to communicate effectively with us, such as:

o Qualified sign language interpreters o Written information in other formats (large print audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages

If you need these services, contact customer service. If you believe that Health Alliance has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Health Alliance Medicare, Member Services, 3310 Fields South Drive, Champaign, IL 61822 or 411 N. Chelan Avenue, Wenatchee, WA 98801, telephone for members in Illinois, Indiana, Iowa and Ohio: 1-800-965-4022; telephone for members in Washington: 1-877-750-3350 TTY: 711, fax: 217-902-9705, MemberServices@healthalliance.org. You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, TTY: 1-800-537-7697. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. ATENCIÓN: Si habla Español, servicios de asistencia lingüística, de forma gratuita, están disponibles para usted. IA,

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